ethical situation

  1. The other day we had a patient who was scheduled to have procedure during the day shift, yet bc of lab results, the procedure was held. During the night, the patient arrested, the procedure done at the bedside stat and we got a rhythm/pulse back. However the pt had been down for quite some time and neurological status was very questionable. Turned out the pt had an advanced directive which we didnt know about. So now we (mainly the docs) were faced with a dilemma... to honor the pt's wishes and urge for the family to withdraw care, or continue treatment now that the pt is "stabilized" somewhat. What does/would one do in that situation? What do u think the family should do?
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  2. 5 Comments

  3. by   talaxandra
    I don't think the team should be blamed for the resuscitation, if nobody knew about the AD. Now that it's existance is known, you and the family have an idea of what the patient would have liked, at least in some situations. I think the best thing to do is give the family the team's best guess about prognosis, particularly neurological, and support them as they decide - they, after all, know the patient's preference best. I would emphasise that the patient had made their wishes known via the AD, perhaps remarking on how hard it can be to know what people wopuld want, as too few people talk about this with their families. Good luck.
  4. by   RoxanRN
    An Advanced Directive does NOT prevent the doctor from acting in a time of emergency (implied consent) barring family direction to the contary (informed consent). I hate to say it, even the DPOA is not legally bound to follow any AD. All it does is give direction to the family (DPOA) in time of distress when decision making is difficult.

    ---- Disclaimer ---- Each state is different! For a definitive answer in your locale, check with your legal team.
  5. by   TennRN2004
    Quote from jbp0529
    The other day we had a patient who was scheduled to have procedure during the day shift, yet bc of lab results, the procedure was held. During the night, the patient arrested, the procedure done at the bedside stat and we got a rhythm/pulse back. However the pt had been down for quite some time and neurological status was very questionable. Turned out the pt had an advanced directive which we didnt know about. So now we (mainly the docs) were faced with a dilemma... to honor the pt's wishes and urge for the family to withdraw care, or continue treatment now that the pt is "stabilized" somewhat. What does/would one do in that situation? What do u think the family should do?
    One important thing we often forget is that these families need to feel that they've given their loved one the best chance at a recovery. It is often hard to give these families at straight answer on prognosis, length of recovery, quality of life if they do live through a period of being sick in the ICU. I personally can't tell you how many I have seen in my few years in the unit and thought they would never make it out of the unit much less the hospital, and they make a full recovery. Granted, the chronic long termers usually don't fare so well, but you never know. I know the families often feel torn between wanting to do what the patient wants, but also not wanting to give up. Nothing would be harder than letting your mom/dad/grandparent go and wondering if you would have continued with treatment if somehow they could have made it.

    Now, all that said, I also think we come to a point when enough is enough. I understand the families that choose to keep going with treatment when there is a feasible chance of recovery, but I have a harder time understanding those who come in with multiple admissions for end stage COPD, fibrotic lungs, chronic CHF with no heart left and the families refuse to recognize they are prolonging the inevitable and making their loved one continue to suffer because they can't let go.

    I think it is a situational thing- each member of the healthcare team must be evaluating the patient and response to treatment on a continual basis with realistic expectations and have frank open discussions to ensure the families understand exactly what is going on. Unfortunately, often these families don't understand half what we tell them, and the half they do understand, they still don't grasp the overall picture of how sick their family member is. I think in these situations, we still have a long way to go with effective communication.
  6. by   BackPackerRN
    All you can do is talk with the family about what the patient would have wanted. The family needs to ultimately make the discision, they are the ones who have to live with that choice. You shouldn't urge the family to withdraw. You need to present them with the facts and options and let them make the choice. Our hospital actually has a pallative care team that has doctors who will review the case and sit down with the family and talk through all the issues. They then also address the issues of comfort during the withdrawal time and make sure we have plenty of pain medication available to keep the patient comfortable. Anyway you look at it, it is not easy.
  7. by   RYNOBLASTER30
    Quote from TennRN2004
    One important thing we often forget is that these families need to feel that they've given their loved one the best chance at a recovery. It is often hard to give these families at straight answer on prognosis, length of recovery, quality of life if they do live through a period of being sick in the ICU. I personally can't tell you how many I have seen in my few years in the unit and thought they would never make it out of the unit much less the hospital, and they make a full recovery. Granted, the chronic long termers usually don't fare so well, but you never know. I know the families often feel torn between wanting to do what the patient wants, but also not wanting to give up. Nothing would be harder than letting your mom/dad/grandparent go and wondering if you would have continued with treatment if somehow they could have made it.

    Now, all that said, I also think we come to a point when enough is enough. I understand the families that choose to keep going with treatment when there is a feasible chance of recovery, but I have a harder time understanding those who come in with multiple admissions for end stage COPD, fibrotic lungs, chronic CHF with no heart left and the families refuse to recognize they are prolonging the inevitable and making their loved one continue to suffer because they can't let go.

    I think it is a situational thing- each member of the healthcare team must be evaluating the patient and response to treatment on a continual basis with realistic expectations and have frank open discussions to ensure the families understand exactly what is going on. Unfortunately, often these families don't understand half what we tell them, and the half they do understand, they still don't grasp the overall picture of how sick their family member is. I think in these situations, we still have a long way to go with effective communication.
    Effectie communication should first begin with the physician whether that be in the ER, ICU, M/S, or Tele. There are to few physicians out there that are honest with the patients and their families. I observe lying on a regular basis. These families buy into it because they are ill informed and don't know any better. Hard for an honest RN to come along after a lying M.D. has already given family false hope. What to do?

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